Anatomic Total Shoulder Arthroplasty Research Articles

Effects of Surgeon-Preferred Staff and Staff Turnover on Operating Time and Complication Rates in Reverse and Anatomic Total Shoulder Arthroplasty.

This study focuses on investigating the risk factors of increased operating room time and patient complication rates after total shoulder arthroplasty cases (both reverse and anatomic). We hypothesize that the use of surgeon-preferred staff will improve operating room efficiency and reduce complication rates while increased staff turnover will decrease efficiency and increase complications. This is a single-center, retrospective study focused on determining the effects of staffing on operating room time and efficiency in total shoulder arthroplasty. The study included patients who underwent total shoulder arthroplasty by a single fellowship-trained orthopaedic surgeon from 2018 to 2023. Four hundred twenty-three patients were included in the study from August 2018 to April 2023, 264 of which were reverse total shoulder arthroplasty (rTSA) and 159 were anatomic total shoulder arthroplasty (aTSA). In both rTSA and aTSA, the presence of surgeon-preferred staff markedly decreased operating room time. In rTSA, staff turnover increased risk of 90-day complications. Because the presence of surgeon-preferred staff affects operating room time and efficiency, orthopaedic surgeons should train multiple surgical teams so that efficiency is not affected by the loss of personnel during a case. To reduce 90-day complication rates in rTSA, staff breaks and turnover should be minimized as much as possible because this has a direct effect on patient outcomes. Effort from hospital administration and management should be put toward reducing turnover to improve patient outcomes.

Trabecular metal backed glenoids in anatomic total shoulder arthroplasty: outcomes after a decade on average

BackgroundFirst-generation trabecular metal (TM) backed glenoids reported poor implant survival and were recalled from the market. Second generation TM glenoids have demonstrated promising findings at short- and mid-term follow-up. In our study, we report on clinical and radiographic outcomes of TM glenoids with an average of 10 years of clinical and radiographic follow-up. MethodsThe charts of 14 TM glenoid patients with minimum 5 years follow-up were retrospectively analyzed. The primary end points included implant survival, range of motion, and patient-reported outcomes. Additionally, radiographic data (metal debris, lateral humeral offset (LHO), acromiohumeral interval (AHI)) were studied. ResultsThe mean age at surgery was 52 ± 11 years and the mean follow-up time was 10 ± 3 years. Implant survivorship was 100%. Range of motion improved significantly following surgery. Forward elevation changed from 120 ± 22º preoperatively to 155 ± 13º postoperatively (P < .01). The mean external rotation showed a statistically significant increase from 19 ± 30º preoperatively to 54 ± 13º postoperatively (P < .01). Internal rotation improved six vertebral levels on average (P < .01). Pain levels decreased significantly from 7 ± 1 to 2 ± 2 (P < .01) while American Shoulder and Elbow Surgeons Shoulder scores increased from 35 ± 10 to 83 ± 21 (P < .01). Simple Shoulder Test scores demonstrated an improvement from 5 ± 3 to 10 ± 3 (P < .01). No patients had glenoid loosening, metal debris, or radioluency on radiographic imaging. The immediate LHO was 18 (standard deviation [SD] ± 9) and final LHO of 16 (SD ± 8) (P value = .01). The immediate AHI was 12 (SD ± 3) and final AHI was 11 (SD ± 3) (P value = .01). ConclusionTM backed glenoids should remain in the modern orthopedic surgeon’s armamentarium of procedures. This particular glenoid design showed 100% implant survival at a decade following surgery, and provided sustained improvements in range of motion and shoulder function in osteoarthritic patients.

Prediction of premorbid three-dimensional anatomy of the glenoid based on statistical shape modeling

BackgroundRestoration of an anatomic joint line after anatomic total shoulder arthroplasty and of the optimal lateral offset after reverse total shoulder arthroplasty may be relatively straightforward when the glenoid does not present with severe erosion. However, in cases of severe glenoid bone loss, the surgeon is left with no preoperative landmark to restore these parameters. The objective of this study was to use statistical shape modeling, to predict the premorbid morphology of the glenoid. We hypothesized that this would allow us to accurately determine premorbid glenoid version and inclination, in addition to accurately quantifying bone loss and medialization. MethodsFifty-six bilateral computed tomography scans of the shoulders of patients scheduled for shoulder arthroplasty and determined to have unilateral osteoarthritis (primary osteoarthritis or cuff tear arthropathy with a healthy contralateral side) were obtained. A statistical shape model was automatically applied on the pathologic arthritic side to predict its premorbid anatomy. Glenoid version, inclination, height, width, and glenoid and scapula lateral offset were measured automatically. These measurements were obtained on the pathological arthritic cases, on the contralateral control healthy cases, and on the premorbid predictions of the pathological arthritic cases and were compared pair by pair. ResultsThe mean difference between the pathological arthritic side and the contralateral healthy side was 9.1° ± 7.3° for version, 4.8° ± 4.8° for inclination, 4.9 ± 4.5 mm for height, 4.7 ± 5.3 mm for width, 2.4 ± 1.9 mm for scapula lateral offset, and the glenoid lateral offset was 1.5 ± 1.5 mm. The mean difference between the premorbid prediction of the pathological side and the contralateral healthy side was reduced to 3.3° ± 2.4° for version, 3.4° ± 2.6° for inclination, 3.0 ± 1.9 mm for height, 2.3 ± 1.4 mm for width, 2.2 ± 1.7 mm for scapula lateral offset, and the glenoid lateral offset was 0.9 ± 0.8 mm. ConclusionThis study shows that statistical shape modeling can allow accurate prediction of the premorbid morphology of the glenoid. This could help optimize implant selection and positioning after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty to restore optimal soft-tissue tension.

After primary shoulder arthroplasty appropriate vancomycin antibiotic prophylaxis does not lead to increased infectious complications when compared to cefazolin

INTRODUCTIONIn primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications. METHODSA retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI). RESULTSThe final cohort included 7,177 primary SA, 6,879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P = .352), superficial complications (0.5% vs. 1.3%; P = .071), PJI (1.1% vs. 1.0%; P = .874), or infectious reoperations (1.1% vs. 1.0%; P = .839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P = .297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered. CONCLUSIONSIn comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA.

Shoulder arthroplasty in the upper extremity weight-bearing patient: a systematic review of clinical outcomes and complications

Patients who rely on their upper extremities for ambulation, or upper extremity ambulators (UEAs), place considerable stress on their shoulders through the use of assistive devices like walkers, crutches, canes, and wheelchairs. It has been postulated that UEAs may be at increased risk for complications following shoulder arthroplasty. This study aimed to systematically review the literature related to (1) patient-reported outcomes measures (PROMs), (2) functional outcomes, and (3) complications in UEAs who undergo shoulder arthroplasty. A systematic review of the PubMed/MEDLINE, Embase, and Cochrane databases was performed to identify studies reporting clinical outcomes of shoulder arthroplasty in UEAs. Patient demographics, clinical characteristics, patient-reported outcomes measures, radiographic outcomes, and postoperative range of motion were collected and compared to control patients (ie bipedal ambulators) from the constituent studies. A total of eight studies evaluating 248 UEA cases and 206 control cases were included for review. Ambulatory assistive devices utilized by UEAs included walkers (39%), wheelchairs (38%), canes (22%), and a crutch (<1%). Among UEA cases, 197 (79%) reverse total shoulder arthroplasty (TSA), 37 (15%) anatomic TSA, and 14 (6%) hemiarthroplasty were performed. Overall, patients exhibited significant improvements in mean American Shoulder and Elbow Surgeons scores, Constant-Murley scores, Simple Shoulder Test scores, and Visual Analog Scale scores postoperatively. Among 3 studies that included comparison with control groups of bipedal ambulators, no significant differences in outcomes were identified. The overall clinical complication rate was 17% for UEAs compared to 9.1% for controls. The rate of revision surgery was 7.7% for UEAs and 4.9% for bipedal ambulators. UEAs experience satisfactory pain relief, functional improvements, and good subjective outcomes following shoulder arthroplasty. However, complication and revision rates are higher compared to those for bipedal ambulators, and the majority of UEAs undergo reverse shoulder arthroplasty compared to anatomic TSA.

Operative time and relative value units for total shoulder arthroplasty based on pathology in the United States

BackgroundDespite total shoulder arthroplasty (TSA) and reverse TSA (rTSA) being fundamentally different procedures, and indicated in different pathologies (rTSA for rotator cuff deficiency [RCD] and proximal humeral fractures [PHFx] and anatomic TSA [aTSA] for glenohumeral osteoarthritis [GHOA]), they have the same Current Procedural Terminology (CPT) code (23472). This paper’s aim is to investigate differences in operative time and work-related value units (wRVUs) per hour among these pathologies, and ultimately determine if there is a need to assign separate CPTs for aTSA and rTSA. MethodsA retrospective cohort of data from the American College of Surgeons–National Surgical Quality Improvement Program was collected, all patients who underwent aTSA or rTSA (CPT: 23472) between the years of 2006 and 2019 for diagnoses of GHOA, RCD, and PHFx were included. Data collected included patient age, body mass index, operative time, and wRVUs per hour. ResultsCompared to GHOA (reference group), the average operative time for the RCD cohort was 12.242 minutes shorter (P < .001), while the wRVUs were higher by 1.627 (P < .001). The average operative time for rTSAs in the PHFx cohort were 17.615 minutes longer (P < .001), while the wRVUs were lower by 2.205 (P < .001). ConclusionThe average operative time for rTSAs for both RCDs and PHFx were longer than that for aTSAs for GHOA. Additionally, wRVUs were lower for rTSAs for RCD and PHFx compared to aTSAs for GHOA. This elucidates inconsistency in reimbursement structure for the procedures, which should be revisited.

Total shoulder arthroplasty for glenohumeral arthritis associated with posterior glenoid bone loss: midterm results of an all-polyethylene, posteriorly augmented, stepped glenoid component

BackgroundThe purpose of this study is to report the minimum 5-year clinical and radiographic outcomes of patients undergoing anatomic total shoulder arthroplasty (aTSA) with a posteriorly augmented glenoid component. MethodsThirty-five shoulders with minimum 5-year follow-up underwent aTSA using a posteriorly augmented glenoid component for the treatment of glenohumeral osteoarthritis with posterior glenoid bone loss. Clinical outcomes included range of motion (ROM), Visual Analog Scale (VAS) for pain, and patient reported outcomes scores (PROS). Radiographs (XR) and computed tomography (CT) scans were obtained to assess glenoid morphology, retroversion, central peg osseous integration (CPOI) via Wirth score, Lazarus scores, and Yian scores. Postoperative outcomes were measured at minimum 2- and 5-year follow-up. Kaplan-Meier survival analysis was calculated. ResultsTwo patients experienced prosthetic instability requiring revision, leaving 33 shoulders with an average follow-up of 6.6 years. Average preoperative glenoid retroversion was 21.6˚. A significant improvement in pain, ROM, and PROS was noted at minimum 2-year and 5-year follow-up. Additionally, VAS pain, American Shoulder and Elbow Surgeons (ASES), and Quick Disabilities of the Arm, Shoulder, and Hand (DASH) scores improved between minimum 2-year and 5-year follow-up. The average Lazarus and Yian scores at final follow-up were 0.73 and 2.6, respectively. There was an increase in Lazarus score and decrease in Wirth score between 2- and 5-year follow-up. A significant correlation was identified between VAS pain scores and both Lazarus and Wirth scores. Survivorship free from revision was 92% at 8.8 years postoperatively. ConclusionsMidterm results of aTSA with a posteriorly augmented, stepped glenoid component demonstrate sustained improvements in clinical outcomes with low rates of radiographic loosening. Continued improvement in pain and function, as well as a minor progression of radiographic osteolysis, may be expected between 2- and 5-year follow-up. Additionally, the severity of radiographic loosening correlates with subjective pain levels.

Staged bilateral total shoulder arthroplasty: a single institutional experience with mid-term follow-up

BackgroundThe preferred surgical approach for surgical treatment of advanced glenohumeral arthritis is shoulder arthroplasty (SA). Considering the growing volume and success of SA, patients with bilateral shoulder disease are likely to undergo surgery on both shoulders. There are numerous studies evaluating the outcomes of bilateral hip and knee arthroplasty, but a paucity of information examining bilateral SA. This study intends to evaluate the clinical outcomes of patients undergoing staged bilateral anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA). MethodsInstitutional records were queried for patients who underwent staged bilateral aTSA or rTSA from 2009 to 2020. Patient records were retrospectively reviewed to assess preoperative and postoperative range of motion (ROM) and strength measurements, demographic information, and complications. Mean ± standard deviation was reported for all continuous variables. Mean functional measurements were compared using a 2-Sample t-Test, ordinal variables via Wilcoxon-Mann Whitney test, and categorical variables via Chi-squared test. Patients were included in the outcome analysis if they had a bilateral TSA with the same procedure (i.e. aTSA on both sides, or rTSA on both sides). Results43 patients (15 male, 28 female) were included. There was an average time of 1.8 years between surgeries. Of the 43 patients, 26 patients had staged bilateral aTSAs and 14 had staged bilateral rTSAs with three patients who had different surgeries on each shoulder. The three patients with different surgeries on each shoulder were excluded from outcome analysis. Patients who had staged aTSA operations demonstrated significant improvement in external rotation (P = .0191, P < .001), forward elevation (FE) (P = .0004, P < .001), and internal rotation (IR) (P = .0183, P = .0166) after the first and second surgeries. Staged rTSA patients showed significant improvement in FE after the first (P = .0043) and second surgeries (P = .016). Patients demonstrated significant increase in strength of external rotation (P = .0136), FE (P = .0088), and IR (P = .0206) after the first rTSA. There was no corresponding increase in strength testing after the second bilateral rTSA surgery. The average Single Assessment Numeric Evaluation, Contralateral Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores for all surgeries were 84 ± 10, 83 ± 13, 75 ± 20, and 9 ± 2, respectively for the first surgery and 82 ± 13, 83 ± 13, 71 ± 21, and 8 ± 3 for the second surgery. ConclusionIndividuals that undergo staged aTSA procedures gain a better ROM and IR strength after both operations. However, individuals that undergo staged rTSA procedures have an improved ROM and strength after the first surgery but limited improvement after the second.

Shoulder arthroplasty outcomes in a series of patients diagnosed with Parkinson’s disease: a retrospective analysis

BackgroundParkinson’s disease (PD) is a neurodegenerative disorder that causes resting tremor and rigidity. Total shoulder arthroplasty (TSA) in patients with PD has proven to be a challenging clinical scenario and is associated with a high risk of complications. The purpose of this study is to explore the relationship between patients diagnosed with PD and outcomes following shoulder arthroplasty (SA). MethodsInstitutional records were queried for patients with PD who underwent SA from 2009 to 2020. Patient medical documentation was retrospectively reviewed to assess demographic information, comorbidity status, preoperative and postoperative range of motion measurements, and complications. Mean ± standard deviation was reported for continuous variables. ResultsA total of 17 patients were identified that met the inclusion criteria. The mean age of the cohort was 57.6 ± 10.6 years at the time of PD diagnosis and 68.1 ± 6.9 years at the time of surgery. The mean follow-up was 1.6 ± 1.2 years. The most common indications for surgery were degenerative joint disease, osteoarthritis, rotator cuff arthropathy, proximal humerus fracture, and rotator cuff tear (1). Mean forward elevation improved from 126.6 ± 24.8° to 131.2 ± 27.8°; mean external rotation improved from 29.4 ± 17.3° to 38.8 ± 10.5°. DiscussionSA is an effective method of improving pain and function in PD patients. Patients undergoing anatomic TSA exhibited the most robust functional improvement in this cohort; however, anatomic TSA was associated with postoperative complications and similar functional measurements were achieved at final follow-up in patients who underwent reverse TSA. Thus, significant care must be taken to ensure the correct implant is chosen on an individual basis to maximize the potential for functional improvement.

Anatomic total shoulder arthroplasty for B2 glenoids treated with asymmetric reaming has equivalent survivorship and patient outcomes compared with type A glenoids at a mean 9-year follow-up

BackgroundWalch B2 glenoids can present a challenge to shoulder arthroplasty surgeons. Short-term studies have demonstrated that corrective reaming to 10° of retroversion in anatomic total shoulder arthroplasty (aTSA) can result in good outcomes, however there is little data reporting the long-term outcomes in this cohort. B2 glenoids treated with high-side reaming present a theoretical risk of early glenoid component failure as one may ream into the subchondral bone. This study aimed to demonstrate that 1) B2 glenoids treated with corrective reaming have durable results and 2) offer similar results to Walch A1/2 in long-term follow-up. MethodsPatients who underwent aTSA by a single surgeon (E.L.F.) were identified from a shoulder arthroplasty registry. Inclusion criteria included Walch A1, A2 or B2 glenoid, a diagnosis of primary shoulder osteoarthritis, and a minimum radiographic and clinical follow-up of 5 years. 43 patients with B2 glenoids were compared to a cohort of 42 patients with A1 or A2 glenoids. Preoperative computed tomography (CT) and radiographs were utilized to assess deformity, glenoid version, and posterior subluxation of the humeral head. Postoperatively, patients were assessed with radiographs and patient-reported outcome measures including American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, and Visual Analog Scale (VAS). Results85 shoulders (82 patients, 42 B2 and 43 A1/A2 glenoids) with an average follow-up of 9.4 years were included. In the B2 cohort, the average retroversion was 21.1° and posterior subluxation was 69.4% compared with 10.6°(p<0.001) and 57.5% (p<0.001) in the A1 or A2 cohort. The cohort demographics were similar except for male sex (B2 69.8% vs A1 or A2 37.2%, p=0.008). There was no difference between the cohorts in their improvement in ASES (p=0.807), SST (p=0.586), or VAS (p=0.930) scores. There was no difference in lateral humeral offset (p=0.889) or acromial humeral interval (p=0.468) between initial postoperative and final follow-up visits. Survivorship for B2 glenoids was 97.6%, 94.1% and 73.3% at 5, 10 and 15 years, respectively compared to 97.6%, 91.9% and 83.5% in type A glenoids. The revision rate was similar between the two groups (p=0.432). Lazarus score (p=0.682) and rates of humeral radiolucency (p=0.366) and humeral osteolysis (p=0.194) were similar between the two cohorts at final follow-up. ConclusionAsymmetric reaming of patients with B2 glenoids is a reliable method of glenoid preparation with excellent mid- to long-term clinical results, patient reported outcomes, and low revision rates similar to their A1 and A2 counterparts.

Two-year follow-up of the SMR stemless platform shoulder system: a multicenter, prospective clinical study

BackgroundThe use of stemless shoulder arthroplasty for osteoarthritis has grown substantially over the past decades. The goal of this study is to evaluate the clinical and radiological outcomes of the Lima SMR Stemless anatomic and reverse total shoulder arthroplasty. Methods73 implants in 73 patients (61 anatomic total shoulder arthroplasties (aTSA) and 12 reverse shoulder arthroplasties (RSA)) were analyzed with a minimum follow-up of 2 years. Average age in the aTSA group was 65,8±8,7 and 78,3±4,8 in the RSA group. Primary osteoarthritis was the indication in most cases (aTSA 93,7%, RSA 67%). Patients were evaluated preoperatively, at 4, 12, and 24 months postoperatively using the Constant Score, the ASES, OSS, EQ-5D-5L, range of motion scores and radiographically. Statistical significance was evaluated using the paired t-test (p<0,05). ResultsAt 2-year follow-up, the overall average Constant Score significantly improved from 40.0 ± 16.7 to 80.9 ± 21.4 (p<0.001). Improvement of the ASES (from 31.7 ± 15.6 to 82.5 ± 19.4) and OSS (from 19.1 ± 7.4 to 41.9 ± 7.9) was also significant (p<0.001). In the aTSA group, all range of motion scores improved significantly (p<0.001). In the RSA group, all range of motion scores improved but only active forward flexion and external rotation in abduction improved significantly (p<0.05). Most patients were satisfied or completely satisfied at 24 months (aTSA 93.9%, RSA 100%). Two humeral implants in the RSA configuration showed loosening on the first postoperative day related to excessive forces exerted on the shoulder, both requiring revision to a stemmed implant.In the aTSA group, no signs of radiolucencies, osteolysis, gradual loosening or migration of the components were seen at final follow-up. In the RSA group, one case had radiolucent lines with subsidence of the humeral core at 12 months which had not progressed at 24 months and was asymptomatic. All other RSA cases showed no radiolucent lines, migration, scapular notching or osteolysis. 3 anatomic implants were converted with retention of the glenoid baseplate and humeral core to a reverse arthroplasty due to atraumatic cuff failure (N=2) and traumatic cuff failure (N=1). After these procedures, patients were satisfied with their results. There were no other complications. ConclusionThe 2-year results presented in this study show good functional and radiological outcomes using the SMR Stemless system.

Anatomical total shoulder arthroplasty revision to reverse shoulder arthroplasty using convertible glenoid: a systematic review of clinical and radiological outcomes.

The aim of the present systematic review is to collect all the available evidence regarding the clinical and radiological results of revision to reverse shoulder arthroplasty (RSA) of modular anatomic shoulder prostheses (TSA) using a convertible metal-backed glenoid (MBG). This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies investigating revision of TSA to RSA utilizing a convertible MBG and reporting clinical and radiological outcomes were identified. A total of five studies on the use of convertible modular glenoid component in the setting of TSA revision to RSA were finally included in the present systematic review. A total of 60 procedures were reported. Mean operative times was 65min. Intraoperative complications included 3 cases of glenoid loosening. Only one case of dislocation was reported as postoperative complication. At mean follow-up of 32.3months post-revision, no glenoid loosening was reported, VAS score decreased from 7.7 to 1.5, Constant Score increased from 24.8 to 57.6. Revision to RSA after failed TSA using a convertible modular glenoid component was associated with a low rate of intraoperative and postoperative complications, low surgical time and led to good results in term of pain relieve and functional outcomes. Given the complexity and risk associated with revision of anatomic shoulder prosthesis having a convertible glenoid may help to simplify the procedure and improve clinical results.

Functionality, complications, and survivorship of total shoulder arthroplasty in patients under 60 years old

BackgroundAs total shoulder arthroplasty (TSA) expands to younger patients, it is crucial to weigh the benefits of early intervention against potential complications and implant longevity in patients under 60 years of age. This study examines mid-term outcomes in this patient subset. MethodsBetween 2009 and 2019, a retrospective analysis was conducted on 50 patients (25 male, 25 female) who underwent anatomic TSA (TSA) under the age of 60 with minimum 5 years follow-up. Demographic and baseline variables were extracted from medical records. Pre-operative and post-operative outcomes of range of motion (ROM) and strength were recorded. Patient-reported outcomes (PROs) were obtained. ResultsFifty patients were followed for an average of 8.7 ± 2.4 years, having a mean age of 54.1 ± 8.4 years. Comparison of pre-operative and post-operative measurements revealed significant improvements in active ROM, including external rotation (ER) (p < 0.0001), forward elevation (FE) (p < 0.0001), and internal rotation (IR) (p = 0.0001). There were significant improvements in functional strength scores, including ER (p = 0.0005) and FE (p = 0.0002). PROs included visual analog scale (VAS) (2.2 ± 2.6), Single Assessment Numeric Evaluation (SANE) (80.3 ± 17.6), American Shoulder and Elbow Surgeons (ASES) score (76.4 ± 22.8), and Simple Shoulder Test (SST) (8.9 ± 3.2). The 5-year and 10-year implant survival rates were found to be 98.0 % and 83.3 %, respectively. There were 7 postoperative complications in 5 patients (14.0 %), including glenoid loosening (n = 2), infection (n = 1), atraumatic instability (n = 1), lesser tuberosity avulsion (n = 1), painful arthroplasty (n = 1) and traumatic rotator cuff insufficiency (n = 1). Subsequently, all 5 patients underwent revision shoulder arthroplasty at an average of 6.5 years after the initial procedure. ConclusionPositive mid to long-term outcomes, including significant improvements in ROM and strength, along with high 5-year and 10-year implant survival rates support TSA as an effective treatment option for patients under the age of 60.

Same-day discharge vs. inpatient total shoulder arthroplasty: an age stratified comparison of postoperative outcomes and hospital charges

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and IP settings. The outcome measures included length of stay (LOS), complications, hospital charges, emergency department (ED utilization), readmissions, and reoperations within 90 days following TSA. Patients with LOS ≤8hours were considered as SDD, and those with LOS >8hours were considered as IP. P<.05 was considered statistically significant. There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (American Society of Anesthesiologists score P=.12, Elixhauser Comorbidity Index P=.067). The SDD cohort was younger than the IP group (SDD 67.0years vs. 73.0 IP years, P<.001), and the SDD group higher rate of intraoperative tranexamic acid use (P=.015) and lower estimated blood loss (P=.009). There were no differences in 90-day overall minor (P=.20) and major complications (P=1.00), ED utilization (P=.63), readmission (P=.25), or reoperation (P=.51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P=.80) and minor (P=.36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS=8.4hours in ≥65 to<75-year cohort vs. LOS=25.9hours in ≥80-year cohort; P<.001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P=.82). SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting.

Shoulder Hemiarthroplasty Is Associated With Higher 30-Day Complication Rates Compared With Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis: A Propensity Score Matched Analysis.

Anatomical total shoulder arthroplasty (TSA) and shoulder hemiarthroplasty (HA) have both been shown to have good outcomes in patients with osteoarthritis of the glenohumeral joint. However, evidence comparing perioperative complications between these procedures in this population is heterogeneous. The American College of Surgeons National Surgical Quality Improvement Program database was queried between the years 2012 and 2021 (10 years in total) for records of patients who underwent either TSA or HA for osteoarthritis of the glenohumeral joint. Patients in each group underwent a 1:1 propensity match for demographic variables. Bivariate and multivariate analyses were performed to compare complications and risk factors between these cohorts. A total of 4376 propensity-matched patients, with 2188 receiving TSA and 2188 receiving HA, were included in the primary analyses. The HA cohort had a higher rate of any adverse event (7.18% vs 4.8%, P=.001), death (0.69% vs 0.1%, P=.004), sepsis (0.46% vs 0.1%, P=.043), postoperative transfusion (4.62% vs 2.2%, P<.001), postoperative intubation (0.5% vs 0.1%, P=.026), and extended length of stay (23.77% vs 13.1%, P<.001). HA was found to increase the odds of developing these complications when baseline demographics were controlled. Older age (odds ratio, 1.040; 95% CI, 1.021-1.059; P<.001) and lower body mass index (odds ratio, 0.949; 95% CI, 0.923-0.975; P<.001) increased the odds of having any adverse event in the HA cohort but not in the TSA cohort. Compared with TSA, HA appears to be associated with significantly higher rates of 30-day postoperative complications when performed for glenohumeral osteoarthritis. [Orthopedics. 2024;47(4):217-224.].

Comparable low revision rates of stemmed and stemless total anatomic shoulder arthroplasties after exclusion of metal-backed glenoid components: a collaboration between the Australian and Danish national shoulder arthroplasty registries

BackgroundThe stemmed anatomical total shoulder arthroplasty is the gold standard in the treatment of glenohumeral osteoarthritis. However, the use of stemless total shoulder arthroplasties has increased in recent years. The number of revision procedures are relatively low and therefore it has been recommended that national joint replacement registries should collaborate when comparing revision rates. Therefore, we aimed to compare the revision rates of stemmed and stemless TSA used for the diagnosis of glenohumeral osteoarthritis using data from both the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the Danish Shoulder Arthroplasty Registry (DSR). MethodsWe included all patients who were registered in the AOANJRR and the DSR from January 1 2012 to December 2021 with an anatomical total shoulder arthroplasty used for osteoarthritis. Revision for any reason was used as the primary outcome. We used the Kaplan-Meier method to illustrate the cumulative revision rates and a multivariate cox regression model to calculate the hazard ratios. All analyses were performed separately for data from AOANJRR and DSR, and the results were then reported using a qualitative approach. Results13066 arthroplasties from AOANJRR and 2882 arthroplasties from DSR were included. The hazard ratio for revision of stemmed TSA with stemless TSA as reference, adjusted for age and gender, was 1.67 (95% CI 1.34-2.09, p<0.001) in AOANJRR and 0.57 (95% CI 0.36-0.89, p=0.014) in DSR. When including glenoid type and fixation, surface bearing (only in AOANJRR) and hospital volume in the cox regression model the hazard ratio for revision of stemmed TSA compared to stemless TSA was 1.22 (95% CI 0.85-1.75, p=0.286) in AOANJRR and 1.50 (95% CI 0.91-2.45, p=0.109) in DSR. The adjusted hazard ratio for revision of total shoulder arthroplasties with metal backed glenoid components compared to all-polyethylene glenoid components was 2.54 (95% CI 1.70-3.79, p < 0.001) in AOANJRR and 4.1 (95% CI 1.92-8.58, p<0.001) in DSR. ConclusionBased on data from two national shoulder arthroplasty registries, we found no significant difference in risk of revision between stemmed and stemless total shoulder arthroplasties after adjusting for the type of glenoid component. We advocate that metal-backed glenoid components should be used with caution and not on a routine basis.

Comparing comorbidity burden between patients undergoing ambulatory rotator cuff repair vs. inpatient anatomic total shoulder arthroplasty

BackgroundRotator cuff repair (RCR) patients routinely undergo same-day discharge in an ambulatory setting, while anatomic total shoulder arthroplasty (TSA) cases have historically been performed in an inpatient hospital setting. For healthier patients, however, TSA has increasingly transitioned to same-day discharge. Understanding whether a true difference in comorbidity burden exists between these patient groups would inform the appropriateness of outpatient TSA in an ambulatory setting. MethodsA retrospective review was performed of patients undergoing primary TSA and same-day, ambulatory RCR performed between September 2017 and May 2021 at a single institution by 3 fellowship-trained orthopedic surgeons. Selected sociodemographic factors and the Elixhauser Comorbidity Index (30 variables) were used to summarize and compare comorbidity burden. Only patients >50 year old were included. Chi-square and Kruskal-Wallis testing was used to compare the prevalence or severity for categorical and continuous variables, respectively. Results1433 cases met inclusion criteria, including 146 (34%) primary inpatient TSAs and 287 (66%) ambulatory RCRs. There were few differences in comorbidity burden between TSA and RCR, with TSA having a significantly higher prevalence for only 4 Elixhauser comorbidities and RCR having a higher prevalence of 1 comorbidity, although none survive a Bonferroni correction. TSA patients had a significantly higher prevalence of uncomplicated (P = .04192) and complicated hypertension (P = .0336), chronic pulmonary disease (P = .0045), and cardiac arrhythmia (P = .0031). The prevalence of diabetes (P = .029758) was significantly higher among RCR patients. Additionally, age (P = .011) was significantly higher among TSA patients. Of the TSA cohort, there were 10 incidences (1%) of 90-day readmission whereas there were 14 incidences (5%) of 90-day readmissions after RCR. ConclusionOverall, few differences in the prevalence of individual comorbidities (and sociodemographic parameters) existed between patients undergoing outpatient RCR and inpatient primary anatomic TSA. Comorbidities with larger differences can be either optimized preoperatively or managed chronically, and given these similarities, TSA may be similarly appropriate for ambulatory settings, particularly as efficiencies in operative time and improvements in regional anesthesia continue to evolve.

Perioperative intravenous dexamethasone use is not associated with periprosthetic joint infection or wound healing complications following shoulder arthroplasty

BackgroundPerioperative intravenous (IV) dexamethasone is commonly used in lower extremity total joint arthroplasty to manage postoperative pain and nausea/vomiting, and recent studies have demonstrated that its use may lower rates of acute postoperative medical complications. However, there is limited information regarding the safety and efficacy of IV dexamethasone in patients undergoing total shoulder arthroplasty (TSA). Additionally, there is concern surrounding corticosteroid use prior to surgery as preoperative corticosteroid injections have been associated with adverse outcomes after TSA, including periprosthetic joint infection (PJI) and revision surgery. Thus, the purpose of this study was to evaluate the effect of perioperative IV dexamethasone on 90-day rates of PJI, wound complications, and medical complications after TSA. MethodsThe Premiere national hospital database was used to identify adult patients undergoing elective TSA between 2016 and 2020; patients were excluded if they were under 18 years old, were undergoing revision TSA, or had a prior proximal humerus open reduction internal fixation (ORIF) procedure. Patients who did and did not receive perioperative IV dexamethasone were then compared in both univariate and multivariate analyses. A Bonferroni correction was utilized to adjust for multiple comparisons. The primary endpoint was risk of acute infectious complications within 90 days of surgery, including PJI and wound infection/dehiscence. Secondary endpoints included acute pulmonary, renal, and thromboembolic complications. ResultsA total of 135,333 patients underwent TSA during the study period; 61.2% underwent reverse total shoulder arthroplasty (RTSA), 33.8% underwent anatomic total shoulder arthroplasty (ATSA), and 5.0% underwent hemiarthroplasty (HA). From 2016 to 2020, perioperative IV dexamethasone use increased by 135%. Multivariate analysis revealed that patients who received perioperative IV dexamethasone did not have increased odds of PJI, superficial wound infection, or wound dehiscence (p = 0.15 – 0.47) but did have decreased odds of sepsis (OR 0.67, 95% CI 0.55-0.81) and other medical complications such as urinary tract infection (UTI) and acute kidney injury (AKI). Additionally, there was a trend towards decreased 90-day hospital readmission (OR 0.88, 95% CI 0.81-0.96, p=0.003). ConclusionsPerioperative IV dexamethasone was not associated with increased risk of acute infectious and wound healing complications. Moreover, patients who received perioperative IV dexamethasone had decreased odds of medical complications and trended towards lower rates of 90-day hospital readmission. The results of this study support the safety of perioperative IV dexamethasone use in patients undergoing elective TSA.

Intraoperative changes to the components planned preoperatively do not affect short-term, postoperative clinical outcomes after reverse total shoulder arthroplasty

BackgroundThree-dimensional, computed tomography preoperative planning has been increasingly adopted among shoulder arthroplasty surgeons. Prior studies have not examined outcomes in patients undergoing reverse total shoulder arthroplasty in which the surgeon implanted prostheses that deviated from the preoperative plan compared to patients in which the surgeon followed the preoperative plan. The hypothesis of this study was that clinical outcomes would not be different between patients in which the surgeon utilized components that deviated from those predicted in the preoperative plan and patients in which the surgeon followed the preoperative plan. MethodsA retrospective review of patients that had preoperative planning for reverse total shoulder arthroplasty from April 2017 through February 2022 was performed. Patients were stratified into two groups: patients in which the surgeon utilized components that deviated from those anticipated by the preoperative plan (changed group), and patients in which the surgeon utilized all of the components anticipated by the preoperative plan (as planned group). Patient-reported outcomes including the Western Ontario Osteoarthritis Index, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Shoulder Activity Level were recorded preoperatively, at one year, and at two years. Preoperative and one-year postoperative range of motion was recorded. ResultsOne hundred and eighty-nine patients were included in this study. One hundred forty-seven patients had intraoperative changes to their preoperative plan and 42 patients underwent reverse total arthroplasty without changes to their preoperative plan. There was no difference determined between any patient-reported outcome score at the one- and two-year postoperative time points between the as planned group and the changed group. No differences were found in range of motion between groups. Patients initially planned to undergo anatomic total shoulder arthroplasty that were intraoperatively converted to a reverse total shoulder arthroplasty had equivalent outcomes compared to those that had 1) other intraoperative deviations or 2) had no changes to their original preoperative plan. ConclusionPatients undergoing reverse total shoulder arthroplasty that had an intraoperative deviation to the components utilized in the preoperative plan had equivalent 1) patient-reported outcomes at one and two years after surgery and 2) range of motion one year after surgery compared to those that did not change from the preoperative plan. This study suggests it is safe to make intraoperative changes to the components utilized in the preoperative plan without concern for inferior postoperative outcomes when performing reverse total shoulder arthroplasty.

Anatomic shoulder arthroplasty in patients 40 years or younger

BackgroundGlenohumeral arthritis in adults less than 40 years old represents a challenging clinical scenario to manage. While patients older than 55 have had reproducible success with current shoulder arthroplasty techniques, young patients have historically had less successful outcomes, possibly due to higher physical demands and more complex pathologies. Despite these concerns, anatomic total shoulder arthroplasty (TSA) remains the treatment of choice for young, active patients with severe glenohumeral arthritis and intact rotator cuff. We hypothesize that TSA provides significant relief in pain and functional outcomes in patients less than 40 years old. MethodsWe performed a single-institution retrospective analysis of consecutive patients aged 40 years and younger who underwent TSA between 2007 and 2022. Demographic data included age, sex, body mass index, Charlson comorbidity index, and preoperative diagnosis. Outcome measures included the Single-Assessment Numerical Evaluation (SANE) score, final range of motion, complications, and revision rate. Statistically significant differences between variables were evaluated using a 2-sample t-test at an α level of P < .05. ResultsTwenty-six TSAs were performed in 23 patients with an average final follow-up of 2 years after the procedure. The average age was 33.4 ± 5.3 years with a range of 19-39 years. The most common preoperative diagnosis was osteoarthritis (46%), followed by rheumatoid arthritis (27%) and osteonecrosis/avascular necrosis (19%). The most common glenoid morphology was type B (15) of which 14 were B2 glenoid, followed by type A (11). The SANE score, mean active forward elevation, abduction, external rotation, and internal rotation all improved significantly (P < .05) by the final follow-up. On average, patients in all groups were able to achieve minimal clinically important difference in SANE score after 1 year. There was 1 complication reported of an early postoperative infection treated with irrigation and débridement, and no revision surgeries were performed during the follow-up period. Discussion/ConclusionTSA significantly improved functional outcome measures in patients less than 40 years old with a low rate of complications and revisions in short-term outcomes. As the frequency of TSA continues to increase in adults less than 40 years old, additional studies recording long-term functional outcomes and implant survivorship in this population can be explored.